Pioneer Trace Group Llc
Pioneer Trace Group LLC in Flemingsburg, KY — inspection on May 27, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
understanding that staff were for assistance. R7 currently has stop sign for door and states is
jeopardy to resident health or residents interviewed on 5/25/2026 felt safe in the facility excluding one resident who's [sic] safety baseline is fearful.-Uninterviewable residents were assessed with a OV PHQ9 on 5/26/2026 by the Social Worker, Unit Nurse managers and Wound nurse. OV PHQ9 assessments completed on 24
regulatory requirements for F-F600 including but not limited to: the need to monitor, intervene and immediately report residents who demonstrate behaviors that present a risk to themselves or other residents; to immediately report all allegations of abuse; and to protect residents involved in an allegation of abuse from further abuse as completed by Administrator, Social worker, DON, Unit Nurse Coordinators, MDS and Wound Nurse by 5/24/2026.
All staff members employed by Pioneer Trace have received in-service.
Human Resources will be responsible for training of new hires and agency if facility were to use agency staff.
Facility will continue to do bi-annually abuse and prevention education and testing as preformed by the social worker.
Facility compelted inservice education to staff on 5/24/2026.
Daily polling of staff to be completed by Administrator or DON to verify competency starting 5/25/2026.
Questions will be asked: What do you do when you witness a resident having behaviors, what are some examples of Deescalation strategies, when do you report abuse.Systems Implemented:-The resident continues on Rexulti 2 mg with noted continued improvement in behaviors.-Resident #2 is still on 1:1 when out of room and 15min.
Checks when in room.-Resident #2 ordered noise reduction earphones as tolerated implemented on 5/14/2026-The facilities Social Worker contacted the resident's day program on 5/22/2026 to determine the types of activities the resident is engaging in, and has added a selection of these to the facility activity program for the resident.-The facilities Social Worker contacted the PASSR agency on 5/22/2026 to determine if any other services are available for the resident.-An Ad Hoc QAPI meeting on 5/22/2026 was conducted with Medical Director, DON and Administrator.
The meeting was held to discuss findings, interventions and impleme11tation related to the citation for abuse and care plans.Monitoring:-The QAPI audit tool for the monitoring of compliance with the F 600 requirements including but not limited to protecting residents from abuse, immediately reporting of abuse allegations, and implementation of care plan interventions for residents with behaviors that may pose a risk of abuse to others.-Interviewable resident will be interviewed daily during IJ period, regarding any-safety concerns in the facility and then every 2 weeks for 1 month, then monthly for 2 months, and then quarterly to determine if there are any resident behavior or other potential risks for abuse that need to be addressed as completed by Social Worker or Administrator.
Social Worker or Administrator will be responsible for reporting results.-During IJ period Administrator or Social Worker to interview residents with the question: Do you feel a sense of safety and security in facility.
Interviews will be conducted on a period of Mondays -Fridays starting on 5/25/2026 and will conclude after IJ period and review with QAPI agrees.-Facility to complete daily AD HOC QAPI meetings daily starting 5/25/2026 during IJ period.Alleged removal date:5/27/2026
185314 05/27/2026
Pioneer Trace Group LLC 115 Pioneer Trace Flemingsburg, KY 41041
checks were initiated and continuous. Resident #5 care-plan was revised to include interventions of
jeopardy to resident health or residents identified with wander risk behaviors had the potential to be affected. 100 % audit was safety completed by unit nurse coordinators for the last 30 days of charted wandering/exit seeking behaviors, 21 residents identified.
Care-plans were reviewed/revised with any indicated
with wander/exit seeking behaviors.
Floor nurses are responsible for adding care-plans on residents with exit seeking behaviors to include interventions which may include increased supervision.Training:All staff have received in-service education on the facility policy/protocol for wander risk management including but not limited to:-Consistent implementation of resident specific care plan interventions for the monitoring and prevention of residents exiting the facility unsupervised.-All staff in-serviced on the procedure for checking outside of a door when the alarm system sounds and for completing a head count to determine that all residents are accounted for.-The increased monitoring process for residents that demonstrate exit seeking behaviors.-All Staff in-serviced on the importance of notifying the DON/Nurses Management/Administrator if wander risk interventions are not effective or if any new wander risk behavior residents are identified so that care plans may be reviewed and revised as needed.-Disciplinary actions that will be implemented for staff that fail to follow the facility protocol for response to door alarms.-Education on care planning, reporting incidents per chain of command and documenting.This training was provided by Administrator, Social worker, DON, Unit Nurse Coordinators, MDS and Wound Nurse by 5/24/2026.
All staff members employed by Pioneer Trace have received inservice.Human Resources will be responsible for training of new hires and agency if facility were to use agency staff.
Facility completed inservice education to staff on 5/24/2026.
Daily polling of staff to be completed by Administrator or DON to verify competency starting 5/25/2026.
Questions will be asked: When should you implement an intervention related to exit seeking, When do you implement a care-plan related to exit seeking, what are some examples of interventions for exit seeking.Systems implemented-100 % audit was completed by unit nurse managers and MDS for the last 30 days of charted wandering/exit seeking behaviors.
Care-plans were reviewed/revised with any indicated interventions, completed by unit nurse managers and MDS on 5/22/2026.-Disciplinary action was implemented for immediate staff involved the day of the elopement for failure to notify and implement interventions.-Ad Hoc QAPI meeting on 05/22/2026 conducted with Medical Director, DON and Administrator.
The meeting was held to discuss interventions and implementation related to elopement and care planning.Monitoring:-Unit nurse managers will audit care-plan documentation for residents identified with wander risk/ behaviors weekly x 4 weeks to determine any need for revisions and will then utilize the QAPI audit tool as outlined below.-Unit nurse managers to review progress notes every morning from the previous day Monday - Friday (weekends to be reviewed following Monday) to identify any wander risk behaviors and will determine that they have been addressed on the care plan.-Facility to complete daily AD HOC QAPI meetings daily starting 5/25/2026 during IJ periodAlleged Removal Date: 5/27/26
185314 05/27/2026
Pioneer Trace Group LLC 115 Pioneer Trace Flemingsburg, KY 41041
competency starting 5/25/2026.Questions will be asked: When should you respond to a door alarm,
jeopardy to resident health or resident when responding to a door alarm.Systems implemented-The Facility did a complete safety accounting for all residents, all residents in the building and or accounted for, this occurred on 5/2/2026.
Completed by floor staff on shift.-Polling of residents completed on 5/2/2026.
Questions
related to asking residents if it is hard to stay inside or ask for help when they want to go somewhere.
Residents who expressed not knowing were educated, no other concerns noted.
Completed by facility nurses.-All residents received an updated assessment for elopement on 5/4/2026 (Resident #5 previously identified as elopement risk and continues to be at risk).
Completed by nursing management.-Maintenance Director contacted door alarm company to change master door code on 5/4/2026, door alarm company responded to facility on 5/5/2026 at 8am and successfully changed master door code and the secondary door code.-On 5/4/2026 all keypads were updated with signage for staff use only completed by the Administrator.-On 5/4/2026 important safety notice was given to residents explaining keypads are to be used by staff only and to ask for assistance when needing to use doors.
Facility Administrator wrote safety notices and activities department delivered to residents.-On 5/4/2026 important safety notice to all visitors was posted on the front doors, notice will be kept up for four weeks and then moved to guest sign in area.
Administrator wrote safety notice and placed it on front door.-Ad Hoc QAPI meeting on 5/5/26 conducted with Medical Director, DON and Administrator.
The meeting was held to discuss interventions and implementation related to elopement.-On 5/21/26 the facility initiated a second staff member to assist with all smoke breaks.
This process also included that when all smoke breaks are completed, smoking assisting staff will notify nurses on duty that smoke break have concluded to eliminate the confusion on door alarms associated with smoke breaks.Monitoring:-The Facility conducted an elopement drill on 5/6/2026 and again on 5/22/26 with no concerns noted, completed by Maintenance Director.
Facility to conduct elopement drills 2x a day for both shifts daily starting Monday 5/25/2026 and continue while facility is in IJ period, will conclude after IJ period and review with QAPI agrees.
Elopement drills will be conducted by Administrator, Maintenance Director or DON.-Facility to complete daily AD HOC QAPI meetings daily starting 5/25/2026 during IJ period.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.